HomeMy WebLinkAbout2026-00015805 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV Xo04175a53
u, 1 U21 1 1 1 U1 7 U2 1 U, 1 u2 1 U, 1 u2 1 1 11 U1 1 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 El ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ®NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 202612026-00015805 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mWALK UT AVE El05:20
® ❑ RELATED ®Y 0 N 03 21 2026 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT l MI NESW GRISWOLD ST COUNTY PROPERTY ❑Y 21N DOORING Ely #OF MOTOR El SLOW 1 cn
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I
lgl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FROhrr TOWED U1 Q
Colin. Mile A. Lexus RX330 2005 00-NONE „ , DUE TO CRASH 0EN
NAME(LAST,FIRST,M) y- mo yr 13-UNDER CARRIAGE 1a.1 2 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m
F 2 SY4 ❑Y ®SNE❑UNK VEH. ATCRASHIN n ENGAGEDn 15-OTHER
99-UNKNOWN 9 76•Top 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI B 4 COM VEH 0 j$J 1 0
I .
ELGIN I N I L 60124 0 1 0 FIRST CONTACT 12 7 ;1 _5 *II Yes.See Sidebar U1
Z FD11196 IL 2026
TELEPHONE
IL D 0 2T2HA31 U35C062889 Progressive ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Conejo, Delfina 942271761 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 73
IR DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0 NMv 0 NOV ❑DV CIRCLE NUMBER(S) U1
!1 9 9 3 Nissan Altima 2020' 00-NONE 11-1 12 NT_, DUE TO CRASH ❑ C 2
o Yr 13-UNDERCARRIAGE tal2 FIRE ❑ ® U2 C
ii;c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP
3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraceon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iII S l,_4 COM VEH D ® Ut W
FIRST CONTACT 6 Y__{_0 -5 If• Yes.SeeSidebar
Z SOUTH ELGIN IL 60177 B 1 0 CE69458 IL 2026 REAR0
M
IL D 1 N4BL4CW8LC233477 Progressive ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 979988230 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 CD 11 1 31 ,21 ,026 03 33 ®pm AM in a Work Zone? NJ DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 ❑ 03 99
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + / ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
-a, ARREST NAME / / ID PM '
o N ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
AM35
Ti 2 El
/ ❑❑PM ❑Unknown work zone type U1
ARREST NAME
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 35
566-Lopez, Eric 701 269-Mendiola , / ❑PM ®N U2
REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS!
A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE
even if units have been moved prior to officer's arrival.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i- ( r 0
f combination): rratingmore than pound (example:truck or truck/trailer
1. Has a weight 10 000 5 -<
INDICATE NORTH o p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
_ } (example:shuttle or charter bus):or
X
0
- ------I----; i 1 - transporting employened to es inthe course passengers5 or fewer thir emplod yment example:employeener X
transporter-usually a van type vehicle or passenger car):or w
L /
4. Is used or designated to transport between 9 and 15 passengers,including C}-----}----; - } } } g po passen rs,includi the driver,
mot,^urdi� for direct compensation(example:large van used for specific purpose):or
-L L__ _a_ _ t i i 'D
5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires
placarding(example:placards will be displayed on the vehicle). m
-1
CARRIER NAME Z
�� lt) _ ADDRESS 0
I C)
CITY/STATE/ZIP g
Not To Scale - MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE